Leading article: What can we do to improve individual and team situational awareness to benefit patient safety?

被引:37
作者
Brennan, P. A. [1 ]
Holden, C. [2 ]
Shaw, G. [2 ]
Morris, S. [3 ]
Oeppen, R. S. [4 ]
机构
[1] Queen Alexandra Hosp, Dept Oral & Maxillofacial Surg, Portsmouth PO6 3LY, Hants, England
[2] Heathrow Airport, Hounslow TW6 1EW, Middx, England
[3] RAF Scampton, Red Arrows Acrobat Team, Red 5, Scampton LN1 2ST, Lincs, England
[4] Univ Hosp, Dept Clin Radiol, Southampton SO16 6YD, Hants, England
关键词
Human factors situational awareness; patient safety; medical error; tunnel vision; team working; ERRORS;
D O I
10.1016/j.bjoms.2020.01.030
中图分类号
R78 [口腔科学];
学科分类号
1003 ;
摘要
It is increasingly being recognised that human factors can contribute to error in complex safety systems. Healthcare, however, has a long way to go before the promotion of training in, and awareness of, human factors will catch up with other high-risk organisations. A critical component that is deemed essential both for improving clinical performance and reducing medical error is situational awareness (SA). This is dynamic and can reduce quickly or be lost entirely, particularly when the workload is heavy. Tunnel vision, in which healthcare professionals concentrate on a single aspect of a patient's care, is just one example of reduced awareness that can be detrimental to safety. As in aviation and other high-risk organisations, a reduction in SA, if not recognised by individuals or the wider team, can lead to serious or potentially fatal outcomes. We therefore give an overview of SA and show how it can easily be reduced. We also suggest some simple but effective ways to improve it and in turn improve patient safety. We emphasise the importance of clinical teams looking out for each other, particularly in the operating theatre. (C) 2020 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
引用
收藏
页码:404 / 408
页数:5
相关论文
共 23 条
  • [1] [Anonymous], 2015, SURG RES PRACT
  • [2] FASA: Development and validation of a novel measure to assess the effectiveness of commercial airline pilot Situation Awareness training
    Banbury, Simon
    Dudfield, Helen
    Hoermann, Hans-Juergen
    Soll, Henning
    [J]. INTERNATIONAL JOURNAL OF AVIATION PSYCHOLOGY, 2007, 17 (02): : 131 - 152
  • [3] Improving patient safety: we need to reduce hierarchy and empower junior doctors to speak up
    Brennan, Peter A.
    Davidson, Mike
    [J]. BMJ-BRITISH MEDICAL JOURNAL, 2019, 366
  • [4] Looking after ourselves at work: the importance of being hydrated and fed
    Brennan, Peter A.
    Oeppen, Rachel
    Knighton, John
    Davidson, Mike
    [J]. BMJ-BRITISH MEDICAL JOURNAL, 2019, 364
  • [5] MEASUREMENT OF SITUATION AWARENESS IN DYNAMIC-SYSTEMS
    ENDSLEY, MR
    [J]. HUMAN FACTORS, 1995, 37 (01) : 65 - 84
  • [6] Building shared situational awareness in surgery through distributed dialog
    Gillespie, Brigid M.
    Gwinner, Karleen
    Fairweather, Nicole
    Chaboyer, Wendy
    [J]. JOURNAL OF MULTIDISCIPLINARY HEALTHCARE, 2013, 6 : 109 - 118
  • [7] SITUATION AWARENESS - SPECIAL ISSUE PREFACE
    GILSON, RD
    [J]. HUMAN FACTORS, 1995, 37 (01) : 3 - 4
  • [8] Training situational awareness to reduce surgical errors in the operating room
    Graafland, M.
    Schraagen, J. M. C.
    Boermeester, M. A.
    Bemelman, W. A.
    Schijven, M. P.
    [J]. BRITISH JOURNAL OF SURGERY, 2015, 102 (01) : 16 - 23
  • [9] Leading article: how can I optimise my role as a leader within the surgical team?
    Green, B.
    Mitchell, D. A.
    Stevenson, P.
    Kane, T.
    Reynard, J.
    Brennan, P. A.
    [J]. BRITISH JOURNAL OF ORAL & MAXILLOFACIAL SURGERY, 2016, 54 (08) : 847 - 850
  • [10] A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population.
    Haynes, Alex B.
    Weiser, Thomas G.
    Berry, William R.
    Lipsitz, Stuart R.
    Breizat, Abdel-Hadi S.
    Dellinger, E. Patchen
    Herbosa, Teodoro
    Joseph, Sudhir
    Kibatala, Pascience L.
    Lapitan, Marie Carmela M.
    Merry, Alan F.
    Moorthy, Krishna
    Reznick, Richard K.
    Taylor, Bryce
    Gawande, Atul A.
    [J]. NEW ENGLAND JOURNAL OF MEDICINE, 2009, 360 (05) : 491 - 499